Root canals, dental implants and saving teeth

“Dentists warn of risks of not looking after implants” was a headline that caught my eye recently when checking the BBC news app. According to the article, there is an epidemic of peri-implantitis. This condition is an infection of the gum and bone around an implant, leading to bone loss and potentially the loss of the implant if the inflammation cannot be controlled.

The story is worrying because it risks causing panic among patients. Many patients consider implants to be indestructible – but they are no different from natural teeth and roots. They must be kept clean and maintained regularly. And smoking is ill-advised.

Disagreement

To my mind, over enthusiastic marketing has had a role to play. Dental implants have been marketed as replacement teeth. It has sometimes been implied that having a dental implant is preferable to saving a tooth which is already causing problems. I don’t agree. Obviously.

An implant is not a replacement tooth, it fills a gap left by a tooth which could not be saved by root canal treatment. This was well expressed in a guide for young dentists produced by the British Society of Periodontology: An implant is not a substitute for a tooth, it’s a substitute for NO tooth.

Saving teeth with root canal treatment

I have spoken publicly several times on the topic of endodontics versus implants, sharing the stage with dentist and implant surgeon Michael Norton. Our presentation was structured as a debate but we always ended up in furious agreement. When a tooth can be saved, it should be. The reasons are clearly set out on this website: www.savingteeth.co.uk

Moving forward, we need clear and responsible marketing of dental implants, we need improved education of patients who have dental implants and more teeth being saved whenever it’s possible. And let’s avoid scare-mongering. A well made dental implant placed by an experienced dentist or specialist in a healthy mouth is an important option for patients and long may it remain so.

The disease and the dilemma

29 June 2015 under Education, Endodontics | Leave a comment

Around one in two adult patients in the UK may have infection beneath their teeth which they are unaware of. This is based on a study at a London teaching hospital which found that 49% of the group had apical periodontitis (AP), the dental name for this kind of oral disease.

Sometimes AP causes the tooth to flare up and sometimes it won’t. Only visible on an X-ray, the chronic disease can remain dormant and painless for years. The dilemma for the dentist is to know whether to intervene and treat the disease when it’s not causing a problem to the patient. Research shows that specialists like myself are more likely to want to treat a tooth when we identify AP from an X-ray, possibly reflecting the confidence that comes from both experience and having a specialist practice fully equipped with specialist technology. This study showed that high quality root canal treatment is crucial to ensure a favourable outcome.

The aim of root canal treatment is to remove all infection from the pulp and root canal system and leave the tooth healthy and functioning in the jaw. Sometimes the attempts to clean out all infection fail. Clearly, the ideal solution would be to improve standards in root canal treatment, reducing the number of people who live with the silent disease.

This bacterial infection spreads from the pulp and into the root canal system. It moves into the bone below the tooth tip where the surrounding tissues respond to the bacteria. This can lead to the bone beneath the tooth reformatting and retreating, leaving a small vacuum. It is this vacuum which can be picked up on an X-ray. The advent of advanced X-ray systems (cone beam computed tomography) makes it easier for dentists to spot the signs of infection.

But there are other reasons why the issue of untreated AP is topical and needs to be resolved. Firstly dental implants are more prevalent and should be placed in strong and healthy bone. Patients who might need and want dental implants shouldn’t be vulnerable to AP.

Furthermore, a link between gum disease and other health issues has been established – http://www.nhs.uk/Livewell/dentalhealth/Pages/gum-disease-and-overall-health.aspx – which suggests that the potential for a link between AP and overall health should either be investigated and proved or, ideally definitively eliminated.

A recent opinion paper in the British Dental Journal sets out the need for such a study. The authors of the paper have helpfully provided a model to help researchers measure the effect of both leaving the disease and treating it.

I believe that as a result of the proposed study, clear guidelines for the benefit of both patients and the profession are almost within our grasp. The debate over whether to intervene when AP is spotted has been simmering for years and needs to be resolved soon.

How do you value a tooth?

11 May 2015 under Its not all Endo! | Leave a comment

How much is each one of your teeth worth to you? Today there are a plethora of websites which will guide you on the price of many different things – houses, cars, clothes, utilities, food, household goods. You name it, the online price comparison site or shopping experience is there for you. You can even determine the cost of frames for your spectacles. But teeth are a different matter entirely.

I was very interested when I saw that the British Endodontic Society had carried out a survey of dentists. The survey found that 98% of dentists had experienced patients opting not to undergo root canal treatment, 42% because they felt it was too expensive. The only remedy for patients in this situation would be an extraction. I know that some patients, if the tooth is a molar, they are happy to have an extraction and a gap. Others are probably thinking that they will fill the gap that’s left behind with an implant. Ironically, the cost of replacing a missing tooth with an implant can be much higher than a root canal treatment.

When a patient has a root canal treatment carried out by me for the first time they are delighted that it isn’t the terrible experience they were anticipating. I use the Wand for delivering a local anaesthetic and this makes the treatment pain free. They are also struck by how complex the procedure is. Once they have experienced two hours of my time, my dental nurse’s time and seen the equipment I use, they have an appreciation for the value of the dentistry that has saved the tooth.

If you are still trying to answer my question about the price you would put on a tooth, feel free to check out this website: www.savingteeth.co.uk

You may not be able to put a price on your tooth, but you will understand its value!

If an endodontic problem is invisible to the human eye, as many are, the case is doomed to failure

9 April 2015 under Endodontics, Saving Teeth Awareness Campaign | Leave a comment

I am grateful to Alpha Omega http://alphaomegauk.co.uk for asking me to carry out a live treatment recently. The picture above shows the treatment underway with myself and my nurse Paulette using the operating microscope. Watched by a handful of dentists, I explained what I do and answered questions; the experience prompted some helpful reflections. The patient in the chair had been referred to me by his dentist to treat infection and pain in an upper right molar. The referring dentist had opened the tooth up but decided that it was best treated by a specialist. What was I going to do? It wasn’t just me asking this question; a group of 7 observers were watching the procedure on a 50 inch plasma screen courtesy of my microscope which recorded the live action!

Numerous craze lines and a superficial fracture running from the front (mesial) to the back (distal) were visible on the surface of the tooth. This alerted me to the possibility that the tooth could be badly cracked or split and this could be the cause of the bone loss between the roots (furcation involvement) seen on the X-ray, leading to swelling in the cheek (buccal swelling)? After I cleaned out the root canals I spotted a fracture running from the mesial marginal ridge to the distal marginal ridge through the floor of the pulp chamber. This was clearly the root of the problem.

Could the patient’s dentist have diagnosed the fracture? The answer is no; only a clinician with an operating microscope could have seen this fracture. The limit of human vision is 0.2mm and anything less than this cannot be seen with a naked eye. I probably see a fracture across the of the pulp chamber floor twice a month. It’s a sobering thought that outside of specialist practice, cases like this would be treated and fail. Thanks to the magnification, we avoid spending time and cost on a hopeless case.

Sadly this particular patient lost his tooth because it tooth was terminally fractured. But at least by cleaning out the canals and dressing the tooth I removed the discomfort and swelling, buying him time to talk to his dentist about the next step – a bridge or an implant.

The moral of my story is that without the correct imaging equipment problems can go undiagnosed. As clinicians we need to have an open mind and remember that the problem inside a tooth may not be visible to the human eye.And as a secondary thought, it’s always beneficial to open yourself up to the scrutiny of your colleagues. It really makes you think about what you do and why.

Death by dental decay

4 March 2015 under Its not all Endo! | 1 Comment

LinenMan_Skull_Front copy copy

Just how devastating it was to have dental decay before the era of modern dentistry is forcefully illustrated by an exhibition at the British Museum called Ancient Lives, new discoveries. The exhibition focuses on the lives of eight people who lived in Egypt and Sudan over several centuries prior to and spanning the start of the Christian era. The bodies have either been embalmed or mummified. Thanks to advances in CT scanning, the bodies are delivering valuable information to researchers. (It’s extraordinary to think that the mummies are being transported to a hospital for scanning and that modern technology can deliver insights into bodies which are centuries old).

The exhibition curators share the information they have gleaned from the body, the grave and any objects the person was buried with. They are unable to tell us how any of them died. What they can tell us is the pathological conditions the people were suffering from.

The most common condition to emerge is dental disease. Four of the bodies – The man embalmed for the Afterlife, Tamut, the priest’s daughter, Padiament the temple doorkeeper and an unusual mummy from the Roman period – had dental abscesses and would have been in considerable discomfort. It’s possible that at least one of the people - The man embalmed for the Afterlife – might have died as a result of the infection entering the bloodstream.

Why was decay a problem? They probably ate a lot of sugar and their molar teeth appear to have been worn down by a fibrous or gritty diet. All aspects of the exhibition are fascinating, especially the way the people worshipped and lived, but undoubtedly to me the most interesting aspect was the insight I got into the appalling burden of dental disease in Ancient civilisations. The exhibition is on until April 19^th . http://www.britishmuseum.org/whats_on/exhibitions/ancient_lives.aspx

© Trustees of the British Museum The image above is the skull of the British Museum’s Man embalmed for the Afterlife; look carefully and below his lower front teeth you will see the hole in the jaw caused by dental abscesses

An endodontist’s route to digital

3 February 2015 under Its not all Endo! | Leave a comment

When I first started on the digital route, I had three aims. The first was to have a website, the second to achieve a paperless practice and the third was to support Gary Carr’s company, The Digital Office. It seemed simple, especially as The Digital Office – or TDO – provides a route to a paperless practice.

I don’t think I had a clear idea of what my practice would look like or the extent to which my website would be so important to my practice marketing. Or that I could be giving a lecture in Belgrade or in Berne or in Bonn and be able to use the TDO app on my iPhone to to call up a patient record and look at their notes and speak to their dentist. For someone who travels a lot, this is hugely reassuring.

At the end of 2014 we launched Rootipedia on this website http://www.roottreatmentuk.com/html/rootipedia. A glossary of common endodontic and dental terminology, it was compiled as an online resource for patients but also intended to have an impact on website optimisation. Hundreds of people visited the website in response to the launch and I can tell which country they were in and exactly when they visited and which of the different communication platforms prompted their visit. This is so different to sending out a brochure!

Dentists who refer to the Harley Street Centre for Endodontics are given a log-in so they can access the records and images of their patients which can be viewed within 15 minutes of the patient’s appointment. The virtue of this is that my referring dentists are always in the picture and I like the respect that this demonstrates. Embracing the digital age has certainly brought some unexpected benefits.

Why evidence matters

26 September 2014 under Education, Endodontics | 1 Comment

Since the mid 1990s, dentists have been required to base their clinical judgements on up-to-date, gold-standard research. We may take evidence-based dentistry for granted nowadays, but when it was introduced in the latter half of the 20^th century, it seemed to herald a new era. Sadly, in a few areas of health, there are still small but vocal groups who prefer to peddle their own extreme theories bearing little relation to the most recent or valid research.

Take for instance the ideas of Weston A Price who lived from 1870 to 1948. His name continues to live on because it suits a very few extremists to continue to propagate his more absurd notions.

Price was a Canadian born dentist who became very interested in nutrition and its relation to dental and physical health. A lot of us would support some of his views – that processed foods, refined sweeteners and additives are best avoided.

Where I, and the rest of the dental profession, part company with Price is on his focal infection theory. He believed that a localized site of infection could disseminate micro-organisms around the body and cause systemic disease. He believed that a tooth that had been endodontically treated would harbour bacteria that could, in time, cause serious illness. His idea of a cure? Extraction of the tooth.

The so-called research he carried out was seriously flawed. Price may have been taken seriously in his time but he was discredited by the 1940s. Today, we can dismiss his theory as ridiculous because it’s not based upon the kind of rigorous, scientific research expected of us.

Unfortunately, there are new generations of extremists who take ideas and attempt to breathe new validity into them. A recent online American site which a worried patient wanted my views on carried a report about Price which had more than 70,000 views and 500 plus comments.

This scare-mongering article describes a root-treated tooth as a “silent incubator “ for highly toxic anaerobic bacteria and suggests that they cause, arthritis, heart attack, kidney disease and more.

In the face of such nonsense, the dental profession needs to do its best to explain the difference between an out-of-date theory and properly conducted research.

We have support from an important quarter: the General Dental Council. I remember reading a landmark judgement dating back some seven or eight years after a dentist was found guilty of serious professional misconduct on a variety of charges relating to an alternative approach to the treatment of one patient. This is what was said to the offending dentist: “Your approach seems to have been to adopt a philosophy and then to seize on all the available evidence which appeared to support it without regard to quality. That is a highly unsatisfactory basis for treatment.”

The very clear expectation of the GDC is that registrants should know how to identify gold standard research.

Unfortunately, we can’t control what our patients find on the internet and no-one seems to have any jurisdiction over what is uploaded there. When I do have a patient who has been exposed to misleading or worrying information, I refer them to the website of the American Association of Endodontists. Their Fact Sheet on the subject is evidence-based and very reassuring: http://www.aae.org/uploadedfiles/publications_and_research/guidelines_and_position_statements/focalinfection.pdf

Not for the squeamish by Trevor Lamb

10 September 2014 under Its not all Endo! | 1 Comment

The radiograph pictured here tells a painful story and could so easily have been avoided. The patient self referred to me because she was in much pain after a root canal treatment by her dentist. Her dentist initially advised extraction the tooth but, rightfully, she wanted it saved.

If you look at the radiograph you will see that two roots have been over-filled with the root canal filling material extruded from the end of the tooth. No surprise the patient was in pain. Each time she went back to her dentist, the pain level increased and she was put on another course of antibiotics – 4 course of antibiotics in total. I must stress that this is unusual and the dentists we work with are skilled clinicians who know when to treat and when to refer.
Sadly the tooth had a poor prognosis and the only solution was to extract it. What a shame and a waste. This tooth would have had an excellent prognosis if treated by the correct hands.
My advice to all patients offered a root canal treatment by their dentist – “Should I be referred to a Specialist Endodontist to do the root canal treatment?”. It may not always be practical, but at least you know that all avenues were explored before you said yes to the treatment.
In this instance, the dentist should definitely have referred the treatment rather than attempting it.
Not for the squeamish

Listen, learn, but what next?

17 July 2014 under Endodontics | 1 Comment

The slogan for the Endodontics Masterclass I chaired in 2014 was “Listen, learn and Implement”. We had a fantastic audience who definitely listened and learned. I wonder what they took back and implemented in their practices?

We had outstanding endodontists in the line-up of speakers: Ghassan Yared, Arnaldo Castelluci, Liviu Steier and Martin Trope all pictured above. Each one espoused his own technique and theories in a very detailed and well argued presentation. All had different canal preparation systems.

Then we had question time when audience members could put their queries to the panel. One dentist confessed to being confused by the different points of view. Having listened to some of the best known speakers in the world, it was difficult to decide which system to invest in. Another dentist asked: “Bearing in mind how long endodontics has been a field of dentistry, why isn’t there some kind of consensus for this?”

We all agreed it was a sad commentary on the state of research – the problem being that you could not get ethical approval for an RCT which would involve treating one cohort of patients in a less than satisfactory way. What we need is for all endodontists to work together and for peer-reviewed journals to insist on research which involves hundreds of patients, not just small groups.
And my advice to the delegates at the Endo Masterclass? Read the literature and follow best advice. As dentists you have the professionalism, experience and judgement to decide which system will work best for you and your patients.one cohort of patients in a way which you thought less than satisfactory. What we need is for all endodontists to work together and for peer-reviewed journals to insist on research which involves hundreds of patients, not just small groups.

Teeth repairing themselves?

17 July 2014 under Education | Leave a comment

It made a lovely story – the new treatment which allows teeth to repair themselves, eliminating fillings. The Daily Mail headline alone made exciting reading – the paper excels in detecting futuristic health stories.

But futuristic is exactly what this story is. If there is a rosy cavity-free future ahead, it’s still a way off. First of all, the process of Electrically Accelerated and Enhanced Remineralisation as the treatment is known, is still in development. The treatment has been devised and researched at Kings College Dental Hospital, and a company has only just been formed to turn this brilliant concept into a product. The company is Reminova Ltd and is in Perth in Scotland.

My real concern are the vast swathes of the population with heavily restored teeth. Large cavities at any age may already have allowed bacteria to enter the dental pulp leading to inflammation and subsequent disease for which the only remedy is root canal treatment.

While there is no doubt that the product is very exciting – it even whitens teeth – a lot more change and patient education needs to take place before all the UK’s population can benefit.

Dr. Julian Webber and Dr. Trevor Lamb

Registered by the GDC as Specialists in Endodontics
121 Harley Street, London W1G 6AX
Tel: +44 (0)20 7935 6393

THE HARLEY STREET CENTRE FOR ENDODONTICS BLOG

Welcome to Julian Webber's blog where he muses on a range of topics including some of his most interesting cases,
stories from his travels, the latest from the clinic and news on our Saving Teeth Awareness Campaign.